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MODERN VIEWS ON THE DIAGNOSIS OF WOUNDS OF THE DIAPHRAGM IN THE THORACIC-ABDOMINAL INJURIES  

Amarantov D.G., Zarivchatskiy M.F., Kholodar A.A., Kolyshova E.V., Gushchin M.O. 

Perm State Medical University named after E.A. Wagner, Perm, Russia 

Patients with thoracoabdominal injuries (TAI) are related to the group of most severe, and the problem of their treatment is still actual [15, 18]. The incidence of TAI is 2.1-25 % of total number of penetrating thoracic and abdominal wounds [8, 12, 13, 17, 29]. The proportion of men was 61.5-92.6 % [2, 10, 15, 16, 31]. In most cases, they were working age patients, mean age of 27.5-34.8 [2, 10, 12, 15, 29, 31].
Some authors report on dominance of abdominal organs injuries in TAI [4, 12, 15]. Other authors present the data on dominance of thoracic injuries [8, 11]. Sometimes, hepatic, splenic and cardiac wounds dominate in TAI. For example, Saganov V.P., Khitreev V.E. et al. [9] report that TAI were in 34 (12 %) patients among 284 patients with cardiac and pericardium wounds. In more than 30-80 % of cases, TAI are combined with other injuries such as blunt abdominal and thoracic trauma, injuries to the neck, extremities and soft tissues of the body, fractures of extremity bones, closed and opened traumatic brain injury and others [4, 8, 15, 18].
Mortality in TAI varies from 3.13 to 20 % [2, 4, 8, 15, 17]. The main causes of death in TAI are acute blood loss, shock, peritonitis, respiratory distress syndrome [15, 24]. Postsurgical complications in TAI encounter in 14.9-53 % of patients [2, 5, 15].
One of specific diagnostic errors in process of arrangement of medical care for patients with TAI is possible failure to detect a diaphragm injury [2, 15, 32]. Identification of a diaphragm wound is usually difficult due to alcohol intoxication of patients, their severe condition, complexity of diaphragm visualizing, prevailing symptoms of thoracic and abdominal injuries and limited time for diagnosis [8, 10]. Moreover, diaphragm injuries do not show any independent clinical symptoms in 43 % of patients [22].
Non-identified diaphragm wounds are identified as formation of diaphragmatic hernia with possibility of abdominal organ entrapment and high mortality after different time intervals after an injury [6, 17, 25, 26]. Even small defects of diaphragm do not recover independently because of diaphragm movements and negative gradient of pressure in the chest during inspiration, resulting in drawing the organs from abdominal cavity to thoracic one [6].
There are some experimental data on a possibility of wound healing without surgery. So, Shatney C.H., Sensaki K. et al. [28] observed a spontaneous healing in 15 of 16 pigs with an experimental diaphragm wound. However there are not any data on a possibility of spontaneous healing of diaphragm in humans. Moreover, the researchers report that diaphragmatic defects in the human do not recover and show signs of diaphragmatic hernias in the long term posttraumatic period. For example, Ya.G. Kolkin, V.V., Khatsko et al. [7] analyzed the results of treatment of 98 (100 %) patients with severe thoracic or abdominal injuries and identified the entrapped diaphragmatic hernias in 7 (7.14 %) of the patients within the period from several months to 32 years after injury. In 6 cases, the hernia was to the left, in one case – to the right.
Some authors believe that formation of entrapped diaphragmatic hernia is possible only in an injury to the left cupula of diaphragm, considering the fact that a diaphragmatic defect is protected by the liver on the right side. For example, Mjoli M., Oosthuizen G. et al. [25] included to their study only patients with left-sided injuries when they studied the possibilities of use of laparoscopy for diagnosis of diaphragmatic wounds in penetrating chest injuries. This opinion is not supported by multiple studies [7, 27]. Particularly, Rivaben J.H., Junoir R.S. et al. [27] conducted an experimental animal study and found the formation of diaphragmatic hernia in 39 % of cases with right diaphragmatic cupula injury with migration of small intestine, the colon and the stomach into the hernial sac.
The above-mentioned facts testify the importance of timely diagnosis of injuries to internal abdominal and thoracic organs, as well as of a diaphragm injury and confirmation of the fact of TAI.
In a case with clear clinical signs of abdominal or thoracic injury with necessity for the classical approach (laparotomy or thoracotomy), diaphragm injuries are usually easily identified during surgery [8, 9, 10, 11, 29]. The specific difficulties in identification of diaphragm injuries appear in unclear clinical picture without requirement of active surgical actions at first glance.
Clinical, sonographic and radiologic studies rarely identify reliable criteria allowing the appropriate diagnosis of a diaphragm injury in patients with TAI: eventration of abdominal organs through the chest wall wound or prolapse into the pleural cavity; hemopneumothorax in presence of a wound on the abdominal wall; hemo- or pneumoperitoneum in absence of an abdominal wall wound [12, 18, 25]. In most cases, clinical manifestations of TAI are not pathognomonic for a diaphragm injury [2, 13]. According to Zaytsev D.A. and Kukushkin A.V. [5], the routine diagnostic techniques identified TAI in only 13 (39 %) of 33 patients.
According to Ukhanov A.P., Gadzhiev Sh.A. [13], the objective studies of patients with TAI more often identify the symptoms of injuries to chest organs: breathing weakness on the appropriate side, in percussion – obtundation or box sound. Subcutaneous emphysema is observed in 30 % of patients. Apnea and delay in the chest half are observed in 62.9 and 37.9 % correspondingly.
Abdominal manifestations of TAI are usually less apparent. Abdominal palpation tenderness is usually moderate. Symptoms of peritoneum sensation are identified in approximately one-third of patients [8]. B.V. Sigua [10] did not find any common symptoms of diaphragm injury in 106 patients with TAI and liver injury. Also clear signs of intraabdominal catastrophe were absent in most cases: guarding was absent in 89 (84.0 %), positive symptoms of peritoneum sensation were in 20 (18.9 %) patients.
Radiologic examination can identify such syndromes as pneumothorax, hemothorax, pneumoperitoneum, migration of abdominal organs into pleural cavity. Kukushkin A.V. [8] performed a radiologic examination of 192 patients with TAI and found pneumothorax in 88.9 % of patients, subtotal and total hemothorax – in 52 (31.5 %), clotted hemothorax – in 16 (8.3 %) patients.
Most patients show the low resolution capability of X-ray method. Nsakala L. [26] pays attention to X-ray sensitivity of 27-60 % for left-sided injuries and 17 % for right-sided ones. According to Thiam O., Konate I. et al. [29], they used radiologic data and could make correct diagnosis in 45 % of cases. Mjoli M., Oosthuizen G. et al. [25] reported that after examination of patients with suspected TAI they identified diaphragm injuries in only 10 (38.5 %) patients among 26 patients with radiologic pathology, whereas diaphragm injuries were found in 12 (42.9 %) patients among 28 patients with normal X-ray images. A.N. Radjou, D.K. Balliga et al. [15] reported that X-ray abnormalities in abdominal cavity had been found in only 52 % of patients. They recommend recurrent chest X-ray examination after 6 hours.
A common technique for TAI diagnosis is ultrasonic investigation (USI). According to Zaytsev D.A., Kukushkin A.V. [5], USI precisely identifies fluid (blood) in pleural and abdominal cavities, but the authors consider that results of USI are the reason for use of invasive techniques to a greater degree.
Many authors testify the high resolution capability of computer tomography (CT) in patients with TAI [6, 30]. Nsakala L. [26] emphasize that CT has sensitivity of 14-61 % and specificity of 76-99 % for identification of TAI. İlhan M., Bulakçı M., et al. [20] showed that CT had diagnosed a diaphragm defect in 80 % of patients among 100 patients with left-sided diaphragm injuries verified by laparoscopy.
However CT is applicable only for stable patients and it does not have absolute sensitivity for diaphragm injuries. Both failure to detect and hyperdiagnosis of diaphragm injuries are possible. For example, Yucel M., Bas G. et al. [32] compared CT data from 43 patients with left-sided penetrating injuries in the thoracoabdominal region to results of laparotomy and laparoscopy. Diaphragm injuries were found in 2 of 30 patients with negative results of CT and only in 9 of 13 patients with CT signs of diaphragm injuries. According to A.N. Radjou, D.K. Balliga et al. [15], multispiral CT was positive in only 33.33 % of patients with TAI.
The researchers note that presurgical diagnosis of TAI according to results of physical, radiologic (with CT) and sonographic examinations is difficult [4, 10, 12, 29]. Even the authors reporting on good results of presurgical diagnosis of TAI testify almost 20 % of presurgically non-diagnosed diaphragm injuries [19]. In a study by Thiam O., Konate I. et al. [29], a diaphragm injury was diagnosed before surgery in 33.3 % of cases, during surgery – in 60 %, during autopsy – in 6.7 %. Therefore, the modern authors recommend active using of invasive diagnosis techniques: laparocentesis, laparo- and thoracoscopy [12].
A.V. Kukushkin [8] used laparocentesis as one of methods for diagnosis of diaphragm injuries in patients with chest wounds. During laparocentesis, the author identified abnormal fluids (blood or intestinal contents) in abdominal cavity in 86 (87.8 %) and 98 (100 %) patients with TAI; in combination with a fact of a wound in the chest region, it was a reliable sign of a diaphragm injury. Nsakala L. [26] reports that thoracoscopy, which is performed even without separate lung ventilation, is a high efficient technique for visualization of diaphragm injuries. Many authors report on high diagnostic possibilities and low traumatic potential of laparoscopy in identification of diaphragm injuries [3, 25]. B.V. Sigua [10] diagnosed TAI in only 7 of 102 cases using chest X-ray examination, but diagnostic laparoscopy for 31 patients identified diaphragm injuries in all cases.
Ashimov Zh.I., Tuybaev E.Z. et al. [3] think that the most efficient diagnostic technique for diaphragm injuries in a thoracoabdominal wound is laparoscopy, for thoracoabdominal wound – thoracoscopy, with their diagnostic efficiency of 94.5 % and 97.2 %. A.M. Danilov, A.P. Mikhaylov et al. [4] recommend to conduct all diagnostic procedures in the surgery room.
It is difficult not to agree with the opinion by Thiam O., Konate I. et al [29] regarding the fact that the best way of diagnosis is to suspect TAI in case of any penetrating thoracic or abdominal injury. However it is unreasonably to conduct even low invasive diagnostic surgery for any wound due to possible complications and hazards. The use of these techniques requires for strict and clear indications.
For determination of such indications, many authors separate the thoracoabdominal region as a part of the body with high possibility of a diaphragm injury in case of presence of a wound [16, 25].
For example, A.N. Radjou, D.K. Balliga et al. [15] identified a diaphragm wound in 10 % of patients with TAI. Yucel M., Bas G. et al. [32] believe that penetrating chest injuries in the left thoracoabdominal region are accompanied by a diaphragm injury in 25-30 % of cases, with 30 % of non-diagnosed cases resulting in subsequent diaphragmatic hernia.
However authors give various interpretations of this field. Some authors believe that this field is located lower the rib 6 [4, 10]. Koto M.Z., Mosai F. et al. [23] limited the thoracoabdominal region by the 4th intercostal space along the midclavicular line superiorly, by the 6th intercostal space along the middle subaxillary line and by the 8th intercostal space along the scapular line and by the lower border of ribs inferiorly. Liao C.H., Hsu C.P. et al. [24] separate the following regions: the thoracic region limited by a horizontal line at the nipple level anteriorly superiorly and posteriorly, and inferiorly – by costal margin; the abdominal region going down from costal margin and limited by a line at the omphalos level inferiorly and anteriorly, and posteriorly – by iliac crests. Yücel M, Özpek A, et al. [31] limit the thoracoabdominal region by the sternum, the 4th intercostal space and costal arc anteriorly and by the spine, the lower border of the scapula and by the lower costal margin posteriorly.
However clinical manifestations, which are common for diaphragm injuries, remain poor in wounds in the thoracoabdominal region. So, Altyev B.K., Shukurov B.I. [2] carried out X-ray examination of the chest and abdomen for 186 and USI for 183 patients with TAI in the thoracoabdominal region. The authors reported that all identified symptoms were specific for TAI; for example, the authors did not find any sings of prolapse of abdominal organs into the pleural cavity.
Many authors agree that the fact of a wound in the thoracoabdominal region requires for active targeted diagnosis for exclusion of a diaphragm wound presence. The researchers have different opinions on a method for visualization of a diaphragm defect. Zaytsev D.A. and Kukushkin A.V. [5] recommend active diagnostic tactics for wounds in the thoracoabdominal region, and, depending on a prevailing syndrome, to conduct thoracotomy, laparotomy, thoraco- or laparoscopy.
Some authors believe that diagnostic laparoscopy is indicated for location of a defect in the thoracoabdominal region [4, 10, 31]. For example, Koto M.Z., Mosai F. et al. [23] performed laparoscopy under general anesthesia for diagnosis of diaphragm injuries in 83 patients with stable hemodynamics and wounds in the thoracoabdominal region. The incidence of diaphragm injuries was 54 %. Laparotomy was conducted for patients with unstable hemodynamics.
Ilhan M., Gök A.F. et al. [21] carried out 26 single-approach and 76 multi-approach laparoscopic procedures for 102 patients with left-sided penetrating injuries in the thoracoabdominal region. Diaphragm injuries were identified in 9 (34.6 %) and 20 (26.3 %) patients correspondingly. It testified the high efficiency and safety of these interventions for diagnosis of abdominal injuries and for making the diaphragm suturing.
Mjoli M., Oosthuizen G. et al. [25] performed diagnostic laparoscopy for 55 patients with left-sided penetrating wounds in the thoracoabdominal region and identified diaphragm wounds in 22 (40 %) patients. D'Souza N, Bruce JL, et al. [16] conducted laparoscopy for 96 patients with left-sided penetrating wounds in the thoracoabdominal region and found diaphragm wounds in 22 (23 %) patients.  
Yücel M, Özpek A et al. [31] offered an algorithm for diagnosis of diaphragm injuries in left-sided wounds in the thoracoabdominal region. The patients with unstable hemodynamics or events of peritonitis received urgent laparotomy. Other patients were observed during 48 hours. Laparotomy was conducted for unstable hemodynamics and development of peritonitis. After 48 hours, other patients received diagnostic laparoscopy with no attention paid to absence of signs of TAI. Among 81 patients, 13 patients received laparotomy, 68 – laparoscopy. 4 diaphragm injuries were diagnosed during laparotomy, 15 – during laparoscopy. The authors noted the high amount of diaphragm injuries in stable patients with absence of peritonitis events, and that presence of hemothorax or pneumothorax did not influence on the rate of identification of diaphragm defects.
Liao C.H., Hsu C.P. et al. [24] implemented a moderately aggressive protocol: 17 patients with location of penetrating injuries in the thoracoabdominal regions and symptoms of a diaphragm injury received 11 diagnostic laparotomies and 6 diagnostic laparoscopies. Diaphragm injuries were found in 13 patients.
Some authors think that thoracoscopy is preferable for diagnosis of diaphragm wounds [2, 26]. Nsakala L. [26] carried out thoracoscopy without separate lung ventilation for 32 patients with TAI and identified diaphragm injuries in 12 (37.5 %) patients. Altyev B.K., Shukurov B.I. [2] believe that videothoracoscopy is indicated only in presence of reliable sings of a penetrating wound (subcutaneous emphysema, discharge of air and organs from the wound, hemo- and pneumothorax).
Revision and primary surgical preparation of the wound has the high importance for diagnosis. Abakumov M.M. [1] offer to perform moderate atypical thoracotomy during wound revision if a defect in the parietal pleura is identified or a penetrating pattern of an injury is confirmed: after wound extending to 12-15 cm, to conduct inspection of pleural cavity, diaphragm, lungs and pericardium.
Therefore, diaphragm injuries in TAI are related to the group of the most difficult injuries to diagnose [14]. There are different opinions on a visualizing technique for the diaphragm if TAI are suspected. The acknowledged insufficient efficiency of non-invasive diagnostic techniques and high risk of non-diagnosed diaphragm injury make it obligatory to continue the implementation of intracavitary endoscopic techniques into diagnosis of diaphragm injuries. It is difficult not to agree with the opinion on current absence of a uniform optimized diagnostic algorithm and surgical management of such patients [17]. 

COCNLUSION

Inconsistent opinion of researchers regarding the borders of the thoracoabdominal region and the absence of a uniform approach to use of invasive techniques in diagnosis of diaphragm injuries show the necessity for future studies for clarification of borders of the thoracoabdominal region and creation of the algorithm for selection of a technique of invasive surgical diagnosis of diaphragm wounds in thoracoabdominal location of a wound. 

Information on financing and conflict of interests

The study was conducted without sponsorship.
The authors declare the absence of clear or potential conflicts of interests relating to publication of the present article.

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